AAO-HNSF Primary Care Otolaryngology Handbook
American Academy of Otolaryngology– Head and Neck Surgery Foundation Primary Care Otolaryngology
©2019 All materials in this eBook are copyrighted by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, 1650 Diagonal Road, Alexandria, VA 22314-2857, and are strictly prohibited to be used for any purpose without prior express written authorizations from the American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. For more information, visit our website at www.entnet.org. Print: First Edition 2001, Second Edition 2004 eBook Format: Second Edition 2004, Third Edition 2011, Fourth Edition 2019 ISBN: 978-0-615-46523-4
We invite you to take a journey into learning the fundamentals of otolaryngology–head and neck surgery. This concise, yet informative handbook is intended to provide the necessary information for medical students and allied health professionals early in their career. It presents the foundation for additional and more detailed exposure at the discretion of the learner. Each chapter reviews the basics of common ear, nose, and throat problems. This fully revised edition also includes a new section on sleep medicine. Since this handbook is designed to expose all practitioners to the fundamentals of otolaryngology–head and neck surgery, it can facilitate the recognition of potentially serious problems that should be referred to an otolaryngologist, as well as provide guidance on how to manage uncomplicated problems that can be taken care of by a patient’s primary care provider. We are grateful to Dr. Gregory Staffel, who first authored this short introduction in 1996 as a primer to medical students rotating in otolaryngology at the University of Texas School for the Health Sciences in San Antonio. The book was originally written in conversational style, peppered with hints for learning, and was very popular with medical students. Dr. Staffel graciously donated his book to the AAO–HNSF to be used as a basis for this handbook. We have endeavored to maintain his straightforward style, while updating the content to highlight contemporary thoughts on each disease and its associated treatment regimen. We are grateful to the many authors and reviewers who have contributed over the years to the success of this publication. We believe that medical students and allied health professionals will find this book both practical and informative in helping you develop the skills necessary to be excellent clinicians. Richard V. Smith, MD AAO–HNSF Coordinator for Education
The editors would like to thank all of the authors who generously gave their time and expertise to review, edit, and author this Primary Care Otolaryngology Handbook – Fourth Edition in the face of busy clinical and academic responsibilities. Cristina Baldassari, MD
Phillip S. LoSavio, MD Benjamin D. Malkin, MD Natasha Pollak, MD Minka L. Schofield, MD Rodney J. Taylor, MD Andrea S. Wang, MD Debra G. Weinberger, MD Philip E. Zapanta, MD
Robert H. Chun, MD Megan L. Durr, MD Erynne A. Faucett, MD Marc J. Gibber, MD Evelyne Kalyoussef, MD Jessica J. Kepchar, DO Dennis J. Kitsko, MD Alan Kominsky, MD
A very special appreciation is extended to Richard V. Smith, MD, AAO–HNSF Coordinator for Education, for his leadership in championing this update and by making this publication accessible on www.entnet.org. The editors also wish to acknowledge the unwavering support of Tirza Lofgreen, CHES, Director of Education, and Miguel Vélez, MA, AAO–HNSF Staff Liaison for the General Otolaryngology & Sleep Education Committee. We thank all of the dedicated professionals who produced this educa- tional handbook. All have shared in the effort, and each individual’s contribution has been outstanding. Stacey L. Ishman, MD, MPH Editor and Chair AAO–HNSF General Otolaryngology & Sleep Education Committee Jeffrey J. Stanley, MD Co-editor and Chair-elect AAO–HNSF General Otolaryngology & Sleep Education Committee
Primary Care Otolaryngology
Table of Contents
1. Introduction to Clinical Rotation and Physical Exam.................................4 2. Presenting on Rounds........................................................................................ 11 3. ENT Emergencies............................................................................................... 14 4. Otitis Media.........................................................................................................22 5. Hearing Loss....................................................................................................... 30 6. Dizziness...............................................................................................................36 7. Facial Nerve Paralysis........................................................................................ 41 8. Rhinology, Nasal Obstruction, and Sinusitis ............................................44 9. Allergy...................................................................................................................53 10. How to Read a Sinus CT Scan....................................................................... 58 11. Maxillofacial Trauma......................................................................................... 61 12. Facial Plastic Surgery......................................................................................... 71 13. Salivary Gland Disease.....................................................................................76 14. Thyroid Cancer................................................................................................... 79 15. Head and Neck Cancer.................................................................................... 84 16. Skin Cancer.......................................................................................................... 91 17. Pediatric Otolaryngology................................................................................ 94 18. Obstructive Sleep Apnea ............................................................................. 106 AAO–HNS Clinical Practice Guidelines and Clinical Consensus Statements.................................................................................................................115 Common Acronyms and Abbreviations............................................................116
Introduction to Clinical Rotation and Physical Exam
The goals of this book are to help guide medical students as they continue to develop the skills necessary to be excellent clinicians. In addition, this book was created to teach the basics of otolaryngology–head and neck surgery. The transition between the basic science and clinical years of medical school often is difficult and overwhelming. After spending two years developing an academic knowledge base on which to build, students are exposed to the challenges of clinical medicine for the first time during the third year. In addition, the third year is often a time of constant change, with short periods of time spent on different rotations and exposed to a vast number of individuals and personalities. To help acclimate students to the environment they are entering, it is important that they consider themselves as part of the medical team that now has the important responsibility of caring for patients. Displaying empathy, attentiveness, and overall professionalism goes a long way in how students are perceived by their senior colleagues and patients. As medical students, it can be difficult at times for you to understand your role in the healthcare team, especially when just starting a rotation. You should work to become an active member of the team . If you show a genuine interest in learning and taking care of patients, your teamwill be more likely to take extra time to teach you. Medical students frequently have extra time to spend with their patients, talking with patients about their past medical problems, family, and social history as they pertain to their disease process. Most important, you should work toward estab- lishing a true patient–physician relationship . This type of relationship establishes the medical student as an important part of the healthcare team, is beneficial to the patient’s overall care, and creates long-term behaviors that translate into the development of an excellent future physician.
Primary Care Otolaryngology
INTRODUCTION TO CLINICAL ROTATION AND PHYSICAL EXAM
One of the most basic attributes a student can develop over the course of the clinical years is the ability to communicate , with both team members and patients. As opposed to the old motto of “see one, do one, teach one,” where the senior members of the team would often leave students on their own in difficult situations, the current environment is more colle- gial and assumes hands-on teaching from the attending physician and residents. It is always okay to say “I don’t know” or “I don’t know how to” when asked a question or to perform a task. Honest communication is best for both learners and patients. While there will always be excep- tions, most people are happy to help students advance their skills and knowledge and will take the time to teach. During the third year, you may have conflicting responsibilities, such as being at a lecture while needing to coordinate a test for a patient. In general, the priority should be the care of the patient. If it is a test and you cannot get someone to do it for you, you may need to miss the lecture. These situations do not actually come up very often, and if patient care is the main goal, over the long run, most people will respect these decisions. However, it is crucial that you communicate with your team in these situations. One of the great things about clinical rotations is the constant influx of knowledge students pick up every day. There is so much new material to absorb it can be overwhelming. It is extremely helpful to identify one or two go-to sources for each rotation that you can refer to when trying to learn about or understand a new condition, treatment, etc. While it is always important to get as much information as possible, large textbooks are often not the best resource as you go through the clinical rotations. Smaller reference books are extremely helpful as a quick guide to the basic understanding needed for all of the new information coming your way. Try to dedicate a specific amount of time every day to reading and always try to read about the conditions or procedures related to your patients. Even though navigating the ever-changing waters of meeting new colleagues, teammates, and patients can be difficult, a simple smile and pleasant demeanor go a long way. Introducing yourself to nurses, advanced practice providers, operating room (OR) staff, and others goes a long way. In high-stress environments, such as the OR, people can be on edge and students can be easy targets for those who want to vent or assert themselves. However, a friendly introduction often disarms those who are inclined to project their own insecurities onto you.
Most important, remember that the clinical rotations are about you! While it is important to work as part of a team, and at times that may mean doing menial tasks, your education should never be compromised. If you find yourself in a situation that is caustic or is compromising your education, identify an advocate who can help you. There are always people who can and will help. It is wise to do this confidentially, but do not hesitate to seek help if needed. There will be no other time during your career when you will be exposed to the sheer vastness that medicine has to offer, so do not let one bad apple ruin that opportunity for you. The second goal of this book is to teach you a little about common ear, nose, and throat (ENT) problems. Since the great majority of you will not become otolaryngologists, it becomes much more important for you to understand how to recognize potentially dangerous problems that should be referred to an otolaryngologist, as well as how to manage uncomplicated problems that can be taken care of at the point of primary care. Head and Neck Exam The ENT history begins with the chief complaint followed by a description of the location, duration, frequency, and quality of the presenting symp- toms. In addition, always inquire about the aggravating and relieving factors . Next, ask the patient about associated symptoms. The following is a short list that can be used: • General/systemic symptoms (fever, chills, cough, heartburn, dizziness, etc.) • Otologic (tinnitus, otalgia, otorrhea, aural fullness, hearing loss, vertigo) • Facial (swelling, pain, numbness) • Nasal (congestion, rhinorrhea, postnasal drip, epistaxis, decreased sense of smell) • Sinus (pressure, pain) • Throat (soreness, odynophagia, dysphagia, globus sensation, throat clearing) • Larynx (vocal changes or weakness, hoarseness, stridor, dyspnea) • Neck symptoms (pain, lymphadenopathy, torticollis, supine dyspnea) The head and neck exam involves inspection (and palpation if practical) of all skin and mucosal surfaces of the head and neck. Otolaryngologists use special equipment to better assess the ears, nose, and throat.
Primary Care Otolaryngology
INTRODUCTION TO CLINICAL ROTATION AND PHYSICAL EXAM
A binocular microscope provides an enlarged, three-dimensional image, giving the physician a superior view of the ear canal and tympanic membrane. The microscope also permits the bimanual removal of wax and foreign bodies. Indirect mirror exam with a headlight permits exami- nation of the larynx, hypopharynx, and nasopharynx. Fiberoptic instru- ments provide a similar ability to examine these regions, but with superior optics. The Ear Assess the external auricle for congenital deformities, such as microtia or preauricular pits. The external auditory canal (EAC) should be examined by otoscopy after being thoroughly cleaned if it is blocked by cerumen. The canal should be assessed for swelling, redness (erythema), narrowing (stenosis), discharge (otorrhea), and masses. The tympanic membrane (TM) is normally pearly gray, shiny, translucent, and concave. Changes in the appearance of the eardrummay indicate pathology in the middle ear, mastoid, or Eustachian tube. White patches, called tympanosclerosis , are often clearly visible and provide evidence of prior significant infection. An erythematous, bulging, opacified TM indicates acute bacterial otitis media. A dull, retracted, amber eardrum can be a sign of serous otitis. If a perforation is present, then the middle ear mucosa may be viewed directly. Healed perforations are often more transparent than the surrounding drum and may be mistaken for actual holes. Pneumatic otoscopy should be performed to observe the mobility of the TMwith gentle insufflation of air. Mobility may be limited by scarring, middle ear effusion, or perforation. Eustachian tube function may be assessed by watching the eardrum as the patient executes a gentle Valsalva maneuver. Tuning forks can be used to grossly assess hearing and to differentiate between conductive and sensorineural hearing loss. A tuning fork placed in the center of the skull (Weber test) will normally be perceived in the midline. The sound will lateralize and be perceived as louder on the affected side in cases of conductive hearing loss. If a sensorineural loss exists, the sound will be perceived in the better or normal hearing ear. The tuning fork is then placed just outside the EAC for the Rinne’s test of air conduction hearing. Placing the base of the tuning fork over the mastoid process allows bone conduction hearing to be assessed. In conductive hearing loss, the tuning fork is heard louder behind the ear (bone conduction is better than air conduction in cases of conductive hearing losses). A proper, complete assessment of hearing requires audiometry. This is indicated in any patient with chronic hearing loss, or with acute loss that
cannot be explained by canal occlusion or middle ear infection. It is also an integral part of the evaluation of the patient with vertigo. The Nose Anterior rhinoscopy should be performed using a bivalve speculum. Evaluate the septum and anterior portions of the inferior turbinates. Topical vasoconstriction with oxymetazoline permits a more thorough examination and allows for assessment of turbinate response to decon- gestion. Nasal patency may be compromised by swollen boggy turbi- nates, septal deviation, nasal polyps, or masses/tumors. The remainder of the nasal cavity can be more carefully examined by performing fiber- optic nasal endoscopy . This allows a more thorough evaluation of the nasal cavity and mucosa for abnormalities, including obstruction, lesions, inflammation, and purulent sinus drainage. The sense of smell is infre- quently tested because of the difficulty of objectively quantifying responses. However, ammonia fumes can be useful for distinguishing true anosmics from malingerers, because ammonia will stimulate trigeminal endings and thus produce a response in the absence of any olfaction. The Mouth An adequate light and tongue depressor are necessary for examining the mouth. The tongue depressor should be used to systematically inspect all mucosal surfaces, including the gingivobuccal sulci, gums and alveolar ridge, hard palate, soft palate, tonsils, posterior oropharynx, buccal mucosa, dorsal and ventral tongue, lateral tongue, and floor of the mouth. Dentures should always be removed to permit a complete examination. The parotid duct orifice (Stenson’s duct) can be seen on the buccal mucosa, opposite the upper second molar. Massage of the parotid gland should express clear fluid. The submandibular and sublin- gual glands empty into the floor of the mouth via Wharton’s ducts. Complete examination of the mouth includes bimanual palpation of the tongue and the floor of the mouth to detect possible tumors or salivary stones. The Pharynx The posterior wall of the oropharynx can be easily visualized via the mouth by depressing the tongue. Inspection of the nasopharynx, hypo- pharynx, and larynx requires an indirect mirror exam or use of a flexible fiberoptic endoscope. All mucosal surfaces are evaluated, to include the Eustachian tube openings, adenoid, posterior aspect of the soft palate, tongue base, posterior and lateral pharyngeal walls, vallecula, epiglottis,
Primary Care Otolaryngology
INTRODUCTION TO CLINICAL ROTATION AND PHYSICAL EXAM
arytenoid cartilages, vocal folds (false and true), and pyriform sinuses. Vocal fold mobility should be assessed by asking the patient to alter- nately phonate and sniff deeply. The glottis opens with inspiration (sniffing) and closes for phonation. The Salivary Glands The parotid and submandibular glands should be inspected and palpated to detect enlargement, masses, and/or tenderness. The Neck The normal neck is supple, with the laryngotracheal apparatus easily palpable in the midline. A complete examination should include external observation for symmetry and thorough palpation of all tissue for possible masses. The exact position, size, and character of any mass should be carefully noted, along with its relationship to other structures in the neck (thyroid, great vessels, airway, etc.). Cranial Nerves A complete head and neck exam includes testing of cranial nerves (CNs) II–XII. A pocket eye chart should be used to test the patient’s vision (optic—CN II). Extraocular eye movements should be tested, along with the pupillary response to light (oculomotor, trochlear, and abducens— CNs III, IV, and VI, respectively). The trigeminal nerve (CN V) can be tested by testing areas of the face using a pin and a wisp of cotton. Having the patient clench his teeth and then open his jaw against resis- tance also tests CN V. Test the facial nerve (CN VII) by having the patient raise his eyebrows, squeeze his eyes shut, scrunch his nose, pucker his lips, and smile. The vestibulocochlear nerve (CN VIII) can be tested with a tuning fork. CN IX (glossopharyngeal) and CN X (vagus) control swal- lowing, the gag reflex, and speech, and so are tested by observing these actions. Have the patient swallow and say “ah, ah, ah.” You can also touch the back of the throat with a tongue depressor to check the gag reflex. Assessment of vocal cord function by flexible fiberoptic laryngoscopy also provides information on the status of the vagus nerve. Assess the function of the spinal accessory nerve (CN XI) by asking the patient to push his head laterally against resistance and shrug his shoulders against resistance. Finally, assess the hypoglossal nerve (CN XII) by having the patient stick out his tongue. Deviation to one side indicates a weakness or paralysis of the nerve on that side.
Differential Diagnosis Every time you see new patients, you begin to formulate a differential diagnosis for them. Most of us begin by doing this randomly, usually the five most recent diagnoses we have seen for this set of symptoms and physical findings. This works when you have seen several thousand patients, but it is not as useful if you have seen only 100 or so. A useful trick is to use an acronym that represents a system based on disease categories (such as “Vitamin C” in the accompanying box). Try it for yourself, and practice using it on all your patients. You will find that this or another system will be a big help in organizing your thoughts when you are confused or during high-stress rounds. V ascular
I nfectious T raumatic A utoimmune (or anatomic) M etabolic I atrogenic or idiopathic
N eoplastic C ongenital
Staying organized is a key component to delivering the best care possible. Identify a system that works best for you in terms of recording and tracking patient information and data. Logs, note cards, and binders are all useful ways to keep track of patients and can guide your learning. Again, do not be afraid to ask questions. There is absolutely no shame in not knowing everything that you have learned or seen once, and always remember this is the time you should be learning as much as you possibly can.
Primary Care Otolaryngology
Presenting on Rounds
Patient presentations should be goal directed and follow this format: • Initial description: Describe the patient’s name, age, gender, and primary diagnosis or diagnoses. » » This often includes the patient’s hospital day and any recent surgical procedures. • Daily updates/tests: Include updates and tests since the last time rounding, such as procedures, imaging, consults, and change in clinical status. • Status/vitals: Note subjective complaints, vitals, and key physical exam findings. » » This often includes the ins and outs, and drain output. • Labs and imaging: Highlight relevant results. • Plan: Include actions that will move the patient closer to discharge. » » Discuss the disposition of tubes, lines, and drains. » » Consider diet and activity as well as consults and imaging. Here is an example following this format: Mr. Jones is a 63-year-old man with a T3 cancer of the tonsil that failed to respond to radiation therapy. He is postoperative day (POD) 3 status post a mandibulotomy, neck dissection, hemiglosectomy and partial pharyngectomy, tracheostomy, and a radial forearm free-tissue transfer for the reconstruction. His pain is well controlled, he is afebrile (with a maximum temperature of 38.2°C [100.8°F]), and his perioperative antibiotics have been discontinued. He is tolerating his tube feeds at 100 cubic centimeters (cc) per hour, and his drains has each put out 30 cc over the last 24 hours.
The last sentence in your presentation should start with “The plan is.…” For example: The plan is to remove the drains today, continue the tube feedings, and start feeding the patient by mouth at one week post surgery. We also plan to cap his tracheostomy tube and remove it if he tolerates having it plugged. We have contacted social work to make sure that he has a place to go when we are ready to discharge him at day 8 or 9 postop. Always think of what you need to do to send patients home. For example, if they are still not eating, the object would be to get them to eat if they are clinically ready. Postoperative Fevers In surgery, the differential diagnosis, as it relates to specific symptoms, depends on the time since the procedure has been completed. For example, if a person has a fever, the most likely cause is dictated some- what by the POD. Remembering the five Ws of postop fever—wind, water, walking, wound, and wonder drugs —as a useful memory tool when you are following patients after surgery. POD 1–2: Wind Atelectasis (without air) often causes a fever. Reasons include being on a ventilator, inadequate sighs during surgery, and (in the general surgery patient) incisional pain on deep breathing. This is treated with incentive spirometry because there is evidence that deep inspiration prevents atel- ectasis better than just coughing. POD 3–5: Water Urinary tract infections are common during this timeframe, especially if Foley catheters are or have been in place. POD 4–6: Walking Deep venous thrombosis can occur. While it is more commonly a problem for patients undergoing pelvic, orthopedic, or general surgery than in head and neck surgery, it needs to be in your differential. Subcutaneous, low-dose heparin and venous compression devices reduce the incidence of thromboembolization . Getting the patient up and walking on POD 1 is the best way to prevent this complication.
Primary Care Otolaryngology
PRESENTING ON ROUNDS
POD 5–7: Wound Most wound infections occur during this period. Preoperative antibiotics are important to prevent or reduce the risk of infection in head and neck surgery that crosses mucosal linings. POD 7+: Wonder Drugs Drugs can cause fevers. (Note that in obstetrics and gynecology, this W is “womb,” and it precedes “wonder drugs.”)
Clinical Consensus Statement: Tracheostomy Care
Airway Airway emergencies are uncommon, but are devastating when they do happen. Whether the patient lives or dies—or worse, lives for years in a coma—depends on the ability of those caring for him or her to recognize, access, and manage the airway. Ear, nose, and throat (ENT) physicians are experts in airway management, but often are not nearby when needed. The advanced trauma life support course you probably have taken or will take emphasizes management of airway emergencies. Predicting when difficulty will occur and being able to manage the diffi- cult airway without it becoming an emergency is an even more valuable skill. Later, this chapter lists three types of airway difficulties that you may encounter. A good rule of thumb about a tracheotomy is: If you think about performing one, you probably should. It is easier to revise a scar on the neck than to bring the dead back to life. If you are not an experienced surgeon and need an immediate surgical airway, then a cricothyrotomy is the preferred procedure. It is easier and less bloody than a tracheotomy. Please remember the airway is best found in the neck by palpation , not inspection. Take a moment and palpate your own cricothyroid membrane , immediately below your thyroid cartilage . To do an emer- gency cricothyrotomy you need only a knife. Feel the space, cut down and stick your finger in the hole, feel again, and cut again and again until you are in the airway. Do not worry about bleeding. Place an endotra- cheal tube in the hole (again, by feel). Be sure not to push it past the carina . By this time, you will be shaking like a leaf—it is okay to let someone else squeeze the bag. Pressure with a dressing will address most bleeding. Occasionally, you may need to use some sutures to stop the bleeding.
Primary Care Otolaryngology
Choanal atresia is a congenital disorder in which the nasal choana is occluded by soft tissue, bone, or a combination of both. When unilateral, it presents with unilateral mucopurulent discharge. When bilateral, the neonate is unable to breathe. Since newborns are obligate nasal breathers, establishing an airway is an acute otolaryngologic emergency. While this should be done in the operating room, a Montgomery nipple can be used as an interim measure prior to surgery. Difficult Intubations Anatomic characteristics of the upper airway, such as macroglossia or congenital micrognathia (e.g., Pierre Robin syndrome), can result in difficult laryngeal exposure. This syndrome is more commonly encountered in young, muscular, overweight men with short necks. Anesthesiologists are trained to recognize and manage the airway in these patients, but everyone caring for them must be aware of the potential difficulty. The need for a surgical airway in these patients often represents a failure of recognition and planning. Ludwig’s Angina and Deep Neck Infections Ludwig’s angina is an infection in the floor of the mouth that causes the tongue to be pushed up and back, eventually obstructing the patient’s airway (Figure 3.1). Treatment requires incision and drainage of the
abscess . The most common cause of this abscess is infection in the teeth. The mylohyoid line on the inner aspect of the body of the mandible descends on a slant , so that the tips of the roots of the second and third molars are behind and below this
line. Therefore, if these teeth are abscessed, the pus will go into the submandibular space and may spread to the parapharyngeal space . Patients with these infections present with unilateral neck swelling, redness, pain, and fever. Usually, the infected tooth is not painful. Treatment is inci- sion and drainage over the submandibular swelling. Antibiotic coverage should include oral cavity anaerobes . If, however, the tooth roots are above the mylohyoid line, as they are from the first molar forward, the infection will enter the sublingual space , Figure 3.1. This photograph depicts a gentleman with severe Ludwig’s angina. Notice the swollen floor of the mouth and the arched, protruding tongue obstructing the airway.
above and in front of the mylohyoid. This infection will cause the tongue to be pushed up and back, as previously noted. These patients usually will require an awake tracheotomy, as the infection can progress quite rapidly and produce airway obstruction. The firm tongue swelling prevents stan- dard laryngeal exposure with a laryngoscope blade , so intubation should not be attempted. Even if there is no airway obstruction on presentation, it may develop after you operate and drain the pus. This results from postoperative swelling, which can be worse than the swelling on initial presentation. Acute Supraglottic Swelling Angioneurotic edema , either familial or caused by a functional or quanti- tative deficiency of C1-esterase inhibitor , can also result in dramatic swelling of the tongue, pharyngeal tissues, and the supraglottic airway (Figure 3.2). Swelling can progress rapidly, and oral intubation may quickly become impossible, requiring an urgent surgical airway. Common
medical treatments are IV steroids, and H1 and H2 histamine blockers. Peritonsillar Abscess This condition is a collection of puru- lence in the space between the tonsil and the pharyngeal constrictor. Typically, the patient will report an untreated sore throat for several days, which has now gotten worse on one side. The hallmark signs of peritonsillar abscess are fullness of the anterior tonsillar pillar, uvular deviation away from the side of the abscess, a “hot potato” voice, and, in some patients, trismus (difficulty opening the jaws). Treatment includes drainage or aspiration, adequate pain control, and antibi- otics. Tonsillectomy may be indi- cated, depending on the patient’s history.
Figure 3.2. Lateral neck, soft-tissue x-ray of a child with acute epiglottis. Note the lack of definition of the epiglottis, often referred to as a “thumb sign” (see Chapter 17, Pediatric Otolaryngology). This can occur as a result of infections—e.g., epiglottitis, which was once common in children. Today, however, these infections are rare because of the widespread use of vaccination against Haemophilus influenzae . Epiglottic or supraglottic edema prevents swallowing. Early recognition of the constellation of noisy breathing, high fever, drooling, and the characteristic posture— sitting upright with the jaw thrust forward—may be lifesaving. Relaxation and an upright position keep the airway open. These children must not be examined until after the airway is secured.
Primary Care Otolaryngology
Foreign Bodies Foreign bodies can present as airway emergencies (Figure 3.3). Usually, however, by the time the patient gets to the emergency room, the foreign body in the airway has been expelled (often by the Heimlich maneuver ), or else the patient is no longer able to be resuscitated. Foreign bodies in the pharynx or laryngeal inlet can often be extracted by Magill forceps after laryngeal exposure with a standard laryngoscope. The patient will
usually vomit, so suction is mandatory. Bronchial foreign bodies will require operative bronchoscopy for removal. Occasionally, a tracheotomy will be required, such as for a patient who has aspirated a partial denture with imbedded hooks. Children often aspi- rate peanuts, small toys, etc., into their bronchi. Occasionally, these patients present as airway emergen- cies, although they more typically present with unexplained cough or pneumonia . Chevalier Jackson, the famous bronchoscopist , has noted, “All that wheezes is not asthma.” In other words, always remember to think of foreign body aspiration when a pediatric patient presents with unexplained cough or pneumonia. If a ball-valve obstruction results, hyper- inflation of the obstructed lobe or segment can occur. This is easier to visualize on inspiration–expiration films . Mucormycosis
Figure 3.3. A coin is seen here trapped in the patient’s esophagus.
This fungal infection of the sinonasal cavity occurs in immunocompro- mised hosts. Typically, mucormycosis appears in patients receiving bone marrow transplantation or chemotherapy. It is a devastating disease, with a significant associated mortality. Mucor is a ubiquitous fungus that can become invasive in susceptible patients, classically those with diabetes with poor glucose regulation who became acidotic . If there is any other system failure (e.g., renal failure ), mortality increases significantly. The
fungus grows in the blood vessels, causing thrombosis and distal isch- emia and, ultimately, tissue necrosis. This also leads to an acidic environ- ment in which the fungus thrives. The primary symptom of mucormycosis is facial pain, and physical exam will show black turbinates caused by necrosis of the mucosa . Diagnosis is made by biopsy . Acutely branching nonseptate hyphae are seen microscopically. Usually the infection starts in the sinuses, but rapidly spreads to the nose, eye, and palate , and up the optic nerve to the brain . Treatment is immediate correction of the acidosis and metabolic stabili- zation , to the point where general anesthesia will be safely tolerated (usually for patients in diabetic ketoacidosis who need several hours for rehydration, etc.). Then, wide debridement is necessary, usually consisting of a medial maxillectomy but often extending to a radical maxillectomy and orbital exenteration (removal of the eye and part of the hard palate) or even beyond. Amphotericin B is the drug of choice. Many patients with mucormycosis also have renal failure, which precludes adequate dosing. Newer lyso- somal forms of amphotericin B have been shown to salvage these patients by permitting higher doses of drugs. If the underlying immuno- logic problem cannot be arrested, survival is unlikely. In patients who are neutropenic, unless the white blood cell count improves, there is no Epistaxis is common and occurs in all people at some time. If the condi- tion is severe or persistent, these people become patients. The most common bleed is from the anterior part of the septum. This area, called Kiesselbach’s plexus, has many blood vessels. In children, these nose- bleeds should be treated with oxymetazoline or phenylephrine nasal spray and digital pressure for 5–10 minutes. It is important for patients to look at the clock while applying the pressure; just 30 seconds can seem like an hour in such a situation, and the patient (or parent) may release the pressure too soon (which allows new blood to wash out the clot that was forming). The most common initiating event for these kinds of nosebleeds is digital trauma from a fingernail. Children’s fingernails should be trimmed, and adults should be informed about avoiding digital trauma. Another consideration may be an occult bleeding disorder; there- chance for survival. Sinus Thrombosis See Chapter 8, Rhinology, Nasal Obstruction, and Sinusitis. Epistaxis
Primary Care Otolaryngology
fore, adequate coagulation parameters should be studied if the patient continues to have problems. Cocaine abuse is a possible etiology in any patient and must be considered. A perforated nasal septum can be a warning sign (Figure 3.4). Recurrent nosebleeds in a teenager can be especially problematic.
Bleeding from the back of the nose in an adolescent male is considered to be a juvenile nasopharyngeal angiofibroma until proven otherwise. These patients frequently also have nasal obstruction. Diagnosis is made by physical examination with nasal endoscopy. Some adult patients, often with hypertension and arthritis (for which they are taking aspirin), have frequent nosebleeds. When they present to the emergency room, they have a significant elevation of blood pressure, which is not helped by the excitement of seeing a brisk nose- bleed. Treatment for these patients is topical vasoconstriction (oxymetazoline, phenylephrine), which almost always stops the bleeding. When the oxymetazoline- soaked pledgets are removed, a small red spot, which represents the source of the bleeding, can often be
Figure 3.4. Septal perforation may be secondary to trauma, cocaine (or even Afrin®) abuse, or prior surgery. Epistaxis commonly accompanies this condition and may be problematic.
seen on the septum. Often, if such a bleeding source is seen, it can be cauterized with either electrocautery or chemical cauterization with silver nitrate. Nasal endoscopy permits identification of the bleeding site, even if it is not immediately seen on the anterior septum. These patients should also be treated with medication to lower their blood pressure. The diastolic pressure must be reduced below 90 millimeters of mercury. Many patients can then go home, using oxymetazoline for a few days. Furthermore, methycellulose coated with antibiotic ointment can be placed into the nose to prevent further trauma and allow the mucosal surfaces to heal. This is usually left in place for three to five days.
Sometimes the bleeding cannot be completely stopped, and packing is used as a pressure method to stop it. If the bleeding is coming from the posterior aspect of the nose, then a posterior pack may need to be placed. An alternative is to place any one of various commercially avail- able balloons to stop the nosebleed. Patients who undergo anterior packing on one side may go home. However, if bilateral nasal packing is used or a posterior pack is placed, patients will need to be admitted to the hospital and carefully watched, because they can suffer from hypo- ventilation and oxygen desaturation. In general, the packing is left in place for three to five days and removed. During this time, prophylactic oral or parenteral antibiotics should be administered to decrease risk of infec- tious complications. If the patient re-bleeds, the packing should be replaced, and arterial ligation, endoscopic cautery, or embolization can be considered. As always, these patients should be worked up for bleeding disorders. A patient with a severe nosebleed can develop hypovolemia, or significant anemia, if fluid is being replaced. These conditions necessitate increased cardiac output, which can lead to ischemia or infarction of the heart. Necrotizing Otitis Externa “Malignant” otitis externa is an old name for what should more appropri- ately be called necrotizing otitis externa. This is a severe infection of the external auditory canal (EAC), usually caused by Pseudomonas . The infec- tion spreads to the temporal bone and, as such, is really an osteomyelitis of the temporal bone . This can extend readily to the base of the skull and lead to fatal complications if it is not adequately treated. This disease occurs most commonly in older patients with diabetes, and can occur in patients with AIDS. Any patient with otitis externa should be asked about the possibility of diabetes. Otitis externa can be caused by traumatic instrumentation or irrigating wax from the ears of patients with diabetes. Patients with necrotizing otitis externa present with deep ear pain, temporal headaches, purulent drainage and granulation tissue at the area of the bony cartilaginous junction in the EAC. Facial nerve paresis followed by other cranial neuropathies in severe cases can be observed. To diagnose an actual infection in the bone (which is the sine qua non of this disease), a computed tomography (CT) scan of the temporal bone, with bone windows, must be obtained. A technetium bone scan will also demonstrate a “hot spot,” but is too sensitive to discriminate between severe otitis externa and true osteomyelitis. The standard therapy is meticulous glucose control; aural hygiene, including frequent ear cleaning; systemic and topical antipseudomonal antibiotics; and hyper-
Primary Care Otolaryngology
baric oxygen in severe cases that do not respond to standard care. Quinolones are the drugs of choice because they are active against Pseudomonas organisms. Complications of Acute Otitis Media Complications include meningitis, sigmoid sinus thrombosis, subperios- teal abscess of the mastoid, brain abscess, and facial nerve paralysis. See Chapter 4, Otitis Media. Sudden Sensorineural Hearing Loss Sudden sensorineural hearing loss (SSHL) is an idiopathic, unilateral, sensorineural hearing loss with onset over a period of less than 72 hours. The most common theories for the etiology are a viral infection or a disorder of inner ear circulation caused by vascular disease. A wide variety of treatments have been used to treat SSHL, including oral and intratympanic steroids, hemodilutional agents, anticoagulants, antivirals, hyperbaric oxygen, and vitamins. The most common treatment for SSHL is a tapered course of oral corticosteroids and/or intratympanic cortico- steroid injections. Regardless, SSHL is a medical emergency that warrants urgent consultation and follow-up with an otolaryngologist. The prognosis is variable and depends on the patient’s age, initial severity of the hearing loss, and promptness of medical treatment.
Clinical Practice Guideline: Acute Otitis Externa Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube
Otitis media may simply be defined as inflammation of the middle ear space , the space between the eardrum and the inner ear. Otitis media is the second-most common disease diagnosed in young children. Otitis media can be classified by duration, patient symptoms, and physical exam findings. It is important for the clinician to be familiar with two common variants of otitis media: (1) acute otitis media and (2) otitis media with effusion . Children with acute otitis media frequently present with sudden onset of fever, ear pain, and fussiness. In patients with acute otitis media, the eardrum is bulging and yellow or white in color with dilated vessels, and there is decreased movement of the eardrum on pneumatic otoscopy (insufflation of air into the ear canal) (Figure 4.1). Common bacteria that cause acute otitis media in children are Streptococcus pneumoniae, Haemophilus influenzae , and Moraxella catarrhalis . In healthy children older than 2 years of age who present with less severe symptoms (mild
otalgia for less than 48 hours and tempera- ture lower than 39°C [102.2°F]), observa- tion for 48 hours may be considered. If the decision is made to treat with anti- bacterial agents, amoxicillin dosed at 80–90 mg/kg per day is the first-line anti- biotic therapy . Azithromycin can be used to treat patients who have a penicillin allergy. The high incidence of resistant organisms can make the treatment of acute otitis media challenging. For example, in patients who do not respond to first-line antibiotic therapy, a beta-lactamase- producing organism or a resistant Streptococcus organismmay be responsible
Figure 4.1. This tympanic membrane (TM) demonstrates the bulging seen with an acute infection.
Primary Care Otolaryngology
for treatment failure. While treatment choices in such patients will be dictated by the prevalence of resistant organisms in your community, a common second-line treatment for acute otitis media is high-dose amoxicillin-clavulanate. Breastfeeding and vaccination with a pneumococcal conjugate prepara- tion may decrease the incidence of acute otitis media in children, while other factors, such as daycare attendance and exposure to tobacco smoke, may predispose children to develop otitis media. Some children develop recurrent acute otitis media , or recurring acute, symptomatic ear infections. These children may benefit from myringotomy tube , or ear tube, insertion if they have three to four bouts of acute otitis media in six months or five to six bouts in a single year. Insertion of ear tubes involves placing small tubes in the eardrum to ventilate the middle ear and prevent negative pressure and fluid buildup (Figure 4.2). Ear tube placement is a short procedure that is often performed on an outpatient basis. Water precautions, such as the use of
ear plugs for swimming and bathing, are not routinely required in children with ear tubes. The ear tubes generally extrude on their own after one to two years. In a child with an open ear tube, ear drainage, either purulent or bloody, typically indicates an ear infection. An advantage of ear tubes is the ability to treat episodes of ear drainage or otor- rhea with topical antibiotic therapy (e.g., fluoroquinolone ototopical drops) applied directly to the ear canal. Currently, there is a trend to use fluoro- quinolone drops rather than traditional neomycin/polymyxin B/hydrocortisone preparations, because of the theoretical risk of ototoxicity associated with the latter medication.
Figure 4.2. Photograph of a TM with a pressure equalizing (PE) tube in place. The tube permits aeration of the middle ear.
Oral antibiotics are not indicated as first-line therapy for children with ear tubes who present with uncomplicated otorrhea. In the past, antibiotic prophylaxis for a three- to six-month trial was an alternative treatment for children with recurrent acute otitis media. Because of concern about the development of resistant organisms, the routine use of antibiotic prophy- laxis for recurrent acute otitis media in otherwise healthy children has been largely abandoned.
Otitis media with effusion , or middle ear fluid without active infection, may occur after treatment of an acute episode of otitis media, or as a result of chronic Eustachian tube dysfunction (Figure 4.3). While the majority of chil- dren will clear middle ear fluid without intervention within three months after an acute ear infection, those with Eustachian tube dysfunction may have persistent middle ear fluid. Children with otitis media with effusion are often asymptomatic, although they may complain of ear fullness or muffled hearing. These patients typically do not have the fevers, irritability, or ear pain that are associated with acute otitis media . On physical examination, there
Figure 4.3. Photograph of a TM with chronic otitis media with effusion. Note the bubbles in the fluid behind the drum. While most effusions will resolve spontaneously, patients with persistent fluid may require tympanostomy tube placement.
may be an air-fluid level behind the eardrum and decreased mobility of the eardrum. Children with otitis media with effusion may have up to a 30–40 decibel (dB) conductive hearing loss, which, in some studies affected speech development and learning. Antibiotic therapy and oral steroids are not indicated for children with otitis media with effusion , as these medications have not shown benefit for clearing middle ear effusion. A course of topical nasal steroids may be prescribed for children with otitis media with effusion who have symptoms of allergic rhinitis. Referral to an otolaryngologist should be considered for children with a middle ear effusion that has persisted for three months or longer. These children will also benefit from a formal audiologic assessment (hearing test) to assess for hearing loss. Children with persistent middle ear effusion associated with hearing and/or speech concerns may benefit from ear tube placement, even if they do not have a history of recurrent ear infections. An adenoidectomy , or removal of the adenoid lymphoid tissue in the nasopharynx, has been shown to reduce the need for ear tubes in some children, presumably by removing a focus of Eustachian tube inflamma- tion. Adenoidectomy is often recommended if a child requires a second set of ear tubes, or if with the first set of tubes the child has significant nasal symptoms. Children usually grow out of the need for ear tubes, as the Eustachian tube assumes a longer and more downward-slanted course with time. However, some subsets of patients, such as children
Primary Care Otolaryngology
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